Basic Information
| Provider Information | |||||||||
| NPI: | 1568976728 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EISEN | ||||||||
| FirstName: | EMILY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2373 64TH ST SW | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493157976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165540918 | ||||||||
| FaxNumber: | 6165543079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3826 44TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495123919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165540918 | ||||||||
| FaxNumber: | 6165543079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2017 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501018371 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501018371 | 01 | MI | LICENSE | OTHER |